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14 The Superomedial Pedicle Breast Reduction Technique: A Simple
and Effective Approach to an Esthetic Breast Reduction . . . . . . . . . . . . . . . . . . . . 199
Soa Santareno
15 Breast Reduction Inferior Dermal Pedicle Technique: Modified . . . . . . . . . . . . . .213
Kulwant S. Bhangoo
16 Breast Reduction with Free Nipple Graft Transfer . . . . . . . . . . . . . . . . . . . . . . . . . 243
Mubariz Mammadli, Mohan Thomas, and James D’silva
Part IV Reconstructive Breast Surgery
17 Breast Reconstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
James D’silva and Akshay Deshpande
18 Technique for Areolar Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Javier Palacios
19 Techniques to Reconstruct the NAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Mohan Thomas and James D’silva
20 Tuberous Breast Deformity Correction: A Simpler Less-Invasive
Technique Using Saline-Inflatable Implants for a One-Stage Correction . . . . . . . 303
Ted S. Eisenberg
Contents
21 Asymmetric Breasts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Mohan Thomas and James D’silva
22 Gynaecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .333
Hassan Nurein
Part V Complications and Their Treatment
23 Breast Implant Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Mohan Thomas and James D’silva
24 Capsular Contracture: Etiology and Treatment Options . . . . . . . . . . . . . . . . . . . . 373
Jacob Haiavy
25 Corrective Breast Surgery After Augmentation, Lift, and Reduction . . . . . . . . . . 383
Marco Romeo and Guillermo Blugerman
Editors and Contributors
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About the Editors
Mohan Thomas is an American-Trained and Board-Certied
Facial Plastic and Cosmetic Surgeon and a Senior Consultant at
Breach Candy Hospital in Mumbai, India. He has graduated from
the University of Pennsylvania and completed his fellowships in
Mt. Sinai Hospital, NewYork. He is chairman and managing director of the Cosmetic Surgery Institute, Mumbai, Pune, and Goa. The
institute under the leadership of Dr. Thomas has been a pioneer and
is still a leader in the eld of cosmetic medicine and surgery. Dr.
Thomas has made signicant contributions to the plastic and aesthetic surgery literature with more than 30 peer-reviewed publications in journals such as the American Academy of Cosmetic
Surgery, Plastic and Reconstructive Surgery, Aesthetic Surgery
Journal, Journal of Plastic Reconstructive and Aesthetic Surgery,
Indian Journal of Plastic Surgery, and the prestigious Clinics of
North America. Dr. Mohan Thomas is on the board of trustees of the
prestigious American Academy of Cosmetic Surgery (AACS) and
the World Academy of Cosmetic Surgery (WAOCS) which is known
for its commitment towards the development of the eld of cosmetic
surgery that delivers the safest patient outcomes through evidencebased information.
JamesD’silva is a board-certied plastic surgeon who has been
in practice as a consultant at the Cosmetic Surgery Institute in
Mumbai. He practices the full scope of cosmetic surgery ranging
from nose surgeries, face rejuvenation, male and female breasts,
all types of body contouring including lifts and weight loss
programs.
He is part of the teaching faculty of the Cosmetic Surgery
Fellowship program through the DY Patil University. His innumerable publications on cosmetic surgery and medicine are noteworthy and appear in most of the international peer-reviewed
journals including the prestigious Clinics of North America and
PRS. He along with Dr. Mohan Thomas has provided the world
community with safety guidelines to be used during body contouring and Brazilian butt lift.
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Contributors
EhabAkkary Akkary Surgery Center, Morgantown, WV, USA
NoopurBansal Indraprastha Apollo Hospital, New Delhi, India
KulwantS.Bhangoo Plastic Surgery, Mercy Hospital of Buffalo, Buffalo, NY, USA
Plastic Surgery, State University of New York at Buffalo, Buffalo, NY, USA
Nitin Bhorkar Consultant Anesthesia, Cosmetic Surgery Institute and Saifee Hospital,
Mumbai, India
GuillermoBlugerman Centro Medico ByS, Buenos Aires, Argentina
KristineBrecht St. Annes Hospital, Burien, WA, USA
JosephJ.Castellano Tampa, FL, USA
AngeloCuzalina Tulsa, OK, USA
JamesD’silva Plastic Surgery, The Cosmetic Surgery Institute, Mumbai, Maharashtra, India
Aesthetic Surgery, The Cosmetic Surgery Institute and D.Y. Patil University, Mumbai, India
Plastic Surgery, The Cosmetic Surgery Institute and The D Y Patil University, Mumbai, India
AkshayDeshpande Plastic and Reconstructive Surgery, Saifee Hospital, Mumbai, India
Editors and Contributors
AnupDhir Indraprastha Apollo Hospital, New Delhi, India
JulianDuran Antonio Narino University, Bogota, Colombia
TedS.Eisenberg Plastic and Reconstructive Surgeon, Philadelphia, PA, USA
Nazareth Hospital, Philadelphia, PA, USA
JacobHaiavy Rancho Cucamonga, CA, USA
Inland Cosmetic Surgery, Rancho Cucamonga, CA, USA
Michael S. Kluska Past President American Academy of Cosmetic Surgery, Southern
Surgical Arts, Chattanooga, TN, USA
GregoryLaurence Germantown Aesthetics, Germantown, TN, USA
MubarizMammadli Aesthetic Plastic Surgeon, Plastic Surgery Clinic, Lisbon, Portugal
VictoriaA.Mañón University of Texas Health Science Center, San Antonio, TX, USA
DanMetcalf Oklahoma City, OK, USA
HassanNurein Royal College of Surgeons of Edinburgh, London, UK
JavierPalacios Veracruz, Mexico
GabrielH.Patino El Cerrito, CA, USA
MarcoRomeo Romeo Aesthetic Group, Private Practice, Madrid, Spain
SoaSantareno Plastic Surgeon, The Dr Pure Clinic, Lisbon, Portugal
Robert Shumway Shumway Cosmetic Surgery and Laser Institute University Center Ln,
San Diego, CA, USA
BradleyC.Stephan Castellano Cosmetic Surgery Center, Tampa, FL, USA
MohanThomas Aesthetic Surgery, The Cosmetic Surgery Institute and D. Y. Patil University,
Mumbai, India
PasqualeG.Tolomeo Exquisite Aesthetics, New York, NY, USA
Part I
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Anatomy
Cosmetic Surgery oftheBreast: “Art,
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Science & Safety”
MichaelS.Kluska
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Highly successful individuals across every eld of life all follow a few simple rules. Whether it be professional athletes or
surgeons, their individual successes are based on the time
devoted to their respective eld, systematic routines, experience, and adapting to their circumstances to ensure that their
goals are accomplished. Described as the “10,000 hour rule”
in the book Outliers, Malcom Gladwell highlights well known
individuals and the commonality they all share on their unique
journey toward success. Although his hypothesis may not be
an exact science, in general the mastering of specic skills
requires continual attempts and to not have fear of failure.
Successful individuals have the ability to adapt, persevere,
overcome adversity, and continue to learn as they craft their
skills. One of the greatest thinkers of our time put it best...
It’s not that I’m so smart, it’s just that I stay with problems longer. —Albert Einstein
When these concepts are applied to the cosmetic surgical
arena, templates and routines develop that provide the physician
and patient with highly reproducible, safe, and efcient procedures that yield esthetically pleasing results with high patient
satisfaction. This combined with an artistic eye to evaluate proportion and a thorough understanding of applied anatomy, allows
today’s surgeon to keep up with the expectations of the modern
day patient, and the ever changing cultural demand of what society labels as a “beautiful breast.” Crafting of these skills affords
cosmetic surgeons the opportunity to make sound judgements
based on training, experience, and patient satisfaction.
1.1 Statistics
Table 1.1
Top ve international cosmetic surgical procedures-2017 Totals
1. Breast augmentation 1.65M
2. Liposuction 1.43M
3. Rhinoplasty 0.79M
4. Abdominoplasty 0.77M
5. Gluteal lift 0.77M
Table 1.2
2018 Cosmetic surgical breast procedures in USA Totals
1. Breast augmentation 313,735
2. Breast implant removal 29,236
3. Breast lift 109,638
4. Breast reduction—female (cosmetic only) 43,591
5. Gynecomastia—men (cosmetic only) 24,753
gical procedures performed with over 313,000 of them being
some form of breast augmentation surgery (Table1.2).
metic breast surgery, account for greater than 27% of all cosmetic surgical procedures performed in the USA on an
annual basis and the numbers continue to rise. Because of
these trends and the fact that each and every patient is unique,
it is imperative that the cosmetic surgeon be well trained and
experienced in surgical breast anatomy. In order to ensure
results are high yield, safe, and consistent, it is imperative
that surgeons understand the multitude of anomalies and
asymmetries that their patients can present with.
Top ve international cosmetic surgery procedures-2017
Cosmetic surgery of the breast 2018 USA statistics
In the USA in 2018, there were 1.8 million cosmetic sur-
These numbers, combined with all other forms of cos-
Statistically, cosmetic surgery of the breast is the most popular procedure worldwide. In 2018, alone, breast augmentation accounted for more than 25% of all international
cosmetic surgical procedures. (Table1.1).
M. S. Kluska (*)
Past President American Academy of Cosmetic Surgery,
Southern Surgical Arts, Chattanooga, TN, USA
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_1
1.2 Anatomy
Breast surgery is an artistic endeavor, an exercise in right brain
creativity. Clarication of patient expectations and knowledge
of individual anatomic characteristics are critical to the surgical
plan.—John Bostwick
Understanding developmental breast anatomy is para-
mount in being able to treat the surgical breast appropriately.
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M. S. Kluska
Although this chapter is not focused on anatomy and physiology, the basics need to be mentioned. The surgeon’s ability
to visualize the breast three dimensionally will provide an
added layer of certainty in the chosen surgical procedure.
Essential anatomy must be considered by the cosmetic
surgeon when operating on the breast and mastering this
anatomy will aid the surgeon in clarifying the appropriate
diagnosis and treatment plan.
During pubertal maturation, the breast takes on a form
that is envied by both the cosmetic surgeon and the aging
patient. Although congenital anomalies may develop, in general it is the youthful breast that we as surgeons are trying to
achieve and that patients so desire.
Fig. 1.1 Anatomy of the
breast as visualized in a cut
section
Developmentally, the mammary gland is an epidermal
appendage that stems from apocrine glands and is essentially
a modied sweat gland. This structure’s progressive development is based on a plethora of regulatory inuences including
hormones, vascular supply, ethnicity, environmental inuences, and weight uctuations. Congenital and acquired disorders of the breast stem from variations in these regulatory
inuences throughout the breast’s entire developmental cycle.
A fully mature breast consists of fatty tissue, breast parenchyma, ligamentous support, sensory, and autonomous
nerves and essential blood supply (Fig.1.1).
Mild asymmetries are the norm in the developing breast
and these asymmetries are treatable, however, it is best
Nipple duct
Central collecting duct
Nipple duct
Central collecting duct
Lactiferous duct
Lactiferous duct
Breast lobule
Superficial layer
of superficial fascia
Brest
lob
Interlobular duct
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advised that the surgeon wait until the patient is both physically and mentally mature. Usually, the age of maturation is
16in females and 18in males.
As a dermally derived organ, the breast originates from
the second to the seventh intercostal space and its general
blood supply and innervation follow these same dermal levels. Externally, the skin of the breast can vary in thickness,
appearance, tone, and quality based on a multitude of factors
including age, history of rapid weight uctuations, pregnancy, heredity, and environmental insults such as smoking
and sun damage. Skin texture, tone, and quality are key contributing factors that must be considered by the surgeon in
order to achieve a successful surgery that results in an esthetically pleasing and functional outcome (Fig.1.2).
Fig. 1.2 Neurovascular supply to the female breast
1.3 Anomalies
The normal breast is not normal
Once the surgeon has mastered knowledge of breast anatomy, he or she will be more comfortable in evaluating any
breast including those that present with asymmetries and
congenital or acquired deformities. The “normal” breast
presents with a wide variety and many times complex variation of anatomy which are rarely symmetrical (Table 1.3)
(Figs.1.3 and 1.4).
These developmental and structural variations are
extremely challenging and must be considered for each and
every breast surgery.
The aging process also presents its own set of unique
challenges in the female breast. From puberty until the
patient’s mid-30s, the female is presented with a breast that
has a few specic functions; the rst function is to provide
nourishment to its offspring and the second is to be attractive
for acquiring a mate, similar to the male peacock and his
beautiful display of feathers. An example of this can be seen
in the nipple-areolar complex enlargement and color change
that occurs during pregnancy. The increase in pigmentation
and size provides the newborn with a quick, recognizable
focal point to gain its nourishment. After the female is
through the child-bearing years, the glandular breast tissue
tends to involute, become atrophic and in some situations be
replaced by fatty tissue. As this occurs, the atrophic breast
begins to become ptotic and changes in size, shape, and location on the chest wall. The natural aging process of the breast
is further inuenced by hormonal changes, diet, exercise,
and environmental factors such as smoking, medication, sun
damage, etc. A surgeon’s understanding of these multifactorial inuences will further allow for the appropriate diagnosis when it comes to cosmetic surgery of the breast.
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Table 1.3 Demonstrates the
classication of the complicating
factors arising from the breast,
thoracic wall, and vertebral
deformities
M. S. Kluska
Fig. 1.3 Tuberous breast deformity in a fully developed 18year old
Fig. 1.4 Previously augmented 30year old who initially presented with severe pes excavatum
1 Cosmetic Surgery oftheBreast: “Art, Science & Safety”
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1.4 Diagnosis: TheArt oftheExam
The key to happiness! If the diagnosis of the initial presenting
problem is wrong, the end result will be wrong.
As stated earlier, in order to appropriately diagnose and treat
the patient’s presenting problem, the surgeon must have an astute
grasp of three-dimensional anatomy. Additionally, the cosmetic
surgeon must also understand overall indications and more
importantly, contraindications for breast surgery (Table1.4). No
matter what the reason is for the initial consultation, the appropriate evaluation and diagnosis are the most important steps in
the outline for successful cosmetic breast surgery.
After initial history of the patient, documentation of the
breast must be carried out. Using time tested routines such as
performing breast measurements on each initial consultation
will lead to consistent repeatable results. That said, it is
important that the surgeon formulate some form of worksheet to record breast anatomy (Fig.1.5).
This type of worksheet helps the surgeon develop and
explain the potential treatment options to the patient and it
can be made a part of the informed consent.
I recommend taking a picture of this for the patient’s
chart and handing them a copy to take home for review.
Following the exam the options for surgery must be
reviewed with the patient. Over the past 20years I have developed my own protocols including sharing with the patient the
ideal principles of cosmetic breast surgery (Table1.5).
Table 1.4 Indications vs. contraindications for cosmetic breast
surgery
Indications Relative contraindications
1. Breasts that are too
large
2. Breasts that are too
small
3. Breasts that have
experienced
involutional change
4. Breasts that display
congenital
anomalies
5. Breast that are
iatrogenically
changed or absent
a
Comorbid conditions include Obesity, Menopause, HTN, Asthma,
COPD, and Diabetes
b
Patients with a history of active or previous radiation and/or chemotherapy, should be handled carefully and only an experienced breast
surgeon should attempt surgery on these patients
1. Patient too young
2. Patient too old or has comorbid
conditions
3. Smoking
4. Undiagnosed breast masses or skin
lesions of the breast area
5. Active breast cancer
6. Active chemotherapy
7. Active radiation therapy
8. Patient presents with an inappropriate
reason for surgery, i.e., “wants breast
surgery because her husband insists
on it”
9. Patient has an iatrogenically changed
breast that the surgeon is not
comfortable handling
10. Patient has unrealistic expectations
a
b
b
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Fig. 1.5 Breast worksheet for recording physical exam as well as, physician and patient signature lines
Table 1.5
Ideal principles of cosmetic breast surgery
1. Create a breast that is proportional to the patient’s body
2. Position the NAC at or slightly above the equator of the breast
mound
3. Create a breast that has fullness without ptosis
4. Create a breast that follows the patient’s normal anatomic lines
5. Create a natural appearing breast
6. Technically develop a breast that has:
(a) Longevity
(b) no rippling
(c) Long-term support
(d) Superior pole fullness
Ideal principles for cosmetic breast surgery
During the exam, it is important to document and discuss
with the patient the anatomy, breast, and skeletal asymmetries and any anomalies. A few of my favorite things to tell
the patient during the exam are...
The good lord didn’t get you perfect and I can’t either, but I will
try my best to improve upon his work.
Think of your breasts as sisters, not twins!
The bigger the implants, the bigger the long term problems.
Whatever your logic, convey to the patient realistic expectations about breast and skeletal asymmetries. Being able to
discuss with them such things as scoliosis and its effect on
the actual breast appearance will strengthen the patient’s
condence in you and further solidify the doctor–patient
relationship.
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M. S. Kluska
Table 1.6
Challenges in cosmetic breast surgery
1. Volume of the breast changes with weight and age
2. Scar location and tension
3. Implant malposition
4. NAC positioning
5. Maintaining the patient’s perceived current size
Challenges in cosmetic breast surgery
Due to breast asymmetries, anomalies, and patient expectations, cosmetic surgery of the breast is artistically and technically the most complex and challenging cosmetic surgery
that surgeons will perform. Many times, breast surgery
involves multiple conicting procedures to restore the breast
to a more youthful appearance and understanding these challenges is the rst step in developing the complicated algorithm necessary to treat diverse breast presentations
(Table1.6).
As a surgeon develops the treatment plan through discussions with the patient, they must take into account multiple
treatment options and be able to concisely and simply communicate these options to each individual patient. I often
refer to this as “the art of the exam.” During this process, the
esthetic surgeon should accomplish several goals including:
(1) establishing a condent patient relationship, (2) reviewing all potential risks and complications with the patient and
family members if present, (3) offering multiple treatment
options when appropriate, and (4) acquiring signed documentation of informed consent. In doing so, the patient
leaves well informed and medico legally, the physician and
the practice have met industry standards. Keep in mind that
how these goals are presented many times facilitates the perceived outcome by both the patient and the surgeon. I recommend the following for establishing a positive encounter
with the patient.
• Always introduce yourself to the patient. So many times
throughout my career, I have observed physicians enter-
ing a room without any form of introduction. This leads to
patient insecurity and hesitancy in choosing YOU as their
potential treating physician.
• Always sit with the patient in an unobtrusive manner.
Having your chair lower than the patient takes away the
intimidation factor of physician over patient and allows
the patient to feel like they are more in control of the con-
sultation. Keep in mind that the patient has come to you
because of research, word of mouth referral, and the ever
increasing inuence of social media. Many times, they
have paid a consult fee or will be spending a lot of money
with you and thus, deserve your respect and gratitude.
Furthermore, if they have a positive experience, they will
tell a few friends and may promote you on their social
media. Conversely, if they have a negative experience,
they will tell anyone who will listen and will post on all
forms of social media.
• Truly listen to your patient’s concerns. Not only does this
help you clearly devise a game plan for them, but it also
helps you determine their motivations, psychological
position and ultimately how realistic their expectations
may be.
• Always have a female in the room with you. This provides
an extra level of condence for the patient, provides you
with a routine that may protect you in a medicolegal situation and provides comfort and relatability for the patient.
• Be thankful! Remember, patients today have extremely
high levels of accessibility to social media, have many
options to choose from, and are willing to travel to have
surgery.
• Always do what is appropriate for the patient, not just
what they want. I often observe physicians making a decision based on what the patient says they want. Yes, it is
the surgeon’s job to provide the patient with what they are
requesting but, it is also the surgeon’s job to guide the
patient to choosing the best procedure for them with the
most longevity and least potential risks. Allowing the
patient to manipulate the decision process many times
leads to poor outcomes. It is our job and duty to inform
the patient of all options and present them with all
associated potential risks and complications. For example, take a patient who presents with a Regnault grade III
ptosis who demands no scar breast augmentation. Placing
an implant in the subglandular position will only create
further ptosis and unaesthetically pleasing result long
term. Conversely, placing an implant in the sub-pectoral
position without a lift will also lead to a poorly shaped
breast. It is the surgeon’s responsibility to be upfront
about the risks and be realistic with the patient about the
potential outcomes.
• Being able to cite clinical statistics to the patient further
instills condence in the patient that you are not only well
trained and experienced, but that you truly have their best
interest at heart. It also helps protect you in untoward outcome and any potential medical legal issues. For example:
a 55-year-old presents for mommy makeover including
cosmetic surgery of the breast and abdomen. She has a
history of smoking but, quit 5months ago and had a total
abdominal hysterectomy with bilateral salpingooophorectomy 3years ago. She’s not on any medications
and stands 5′3″ tall and weighs 170 pounds. Currently,
she wears a 38CC and wants lifted and larger breasts. She
does not exercise and has a family history of diabetes
mellitus but, claims that her current blood sugars are controlled by diet. On physical exam she has signicant
breast ptosis and marked lipodystrophy of the axillary
folds with mild stria of the breast skin. Not taking into
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